See also
Acute Poisoning – guideline for initial management
Resuscitation
Hydrocarbon Poisoning
Eucalyptus oil Poisoning
Camphor Poisoning
Salicylates Poisoning
Key points
- Mucous membrane irritation and gastrointestinal symptoms usually develop first, followed by CNS depression, increasing the risk of aspiration pneumonitis
- Specific symptoms occur with specific oils, contact poisons for further information especially if specific ingestant known
- Aspiration pneumonitis is a risk from both the essential oil and from hydrocarbons or emulsifiers that are added to many preparations
For 24 hour advice, contact the Victorian Poisons Information Centre on 13 11 26
Background
Essential oils are a common household product used for medicinal, aromatic, cleaning and other purposes. Common essential oils include Lavender, tea tree, nutmeg, sage, peppermint, wintergreen (see Salicylates Poisoning), fennel, geranium, lemon myrtle, thuja, woodworm and clove. Toxicity can occur from the essential oil itself along with the hydrocarbons (see Hydrocarbons Poisoning) or emulsifiers added to many of the preparations. For eucalyptus oil ingestions see the separate Eucalyptus oil Poisoning guideline.
Pharmacokinetics:
Essential oil concentrations range from 1-20% and volumes of 5-15 mL are likely to cause some degree of toxicity.
Essential oils mimic other fat soluble drugs, are well absorbed through mucous membranes and the skin and are excreted unchanged or as hepatic metabolites via lungs, urine, faeces and skin.
Dose related toxicity: 5–15 mL should be considered a potentially toxic dose in adults, for some essential oils 2-3 mL ingestions have been associated with toxicity in children. Expect mucous membrane irritation and gastrointestinal symptoms with possible CNS depression.
Patients requiring assessment
All patients with deliberate self-poisoning or significant accidental ingestion
Any symptomatic patient
Dose >5 mL
Any patient whose developmental age is inconsistent with accidental poisoning as non-accidental poisoning should be considered.
Risk Assessment
History
Intentional overdose or accidental
Dose
Stated or likely dose taken
Preparation type and % concentration
If possible determine the exact name and amount/volume taken.
Co-ingestants eg paracetamol
Examination
CNS: CNS depression (any decrease is significant), vertigo, dizziness, ataxia, seizures.
CVS: bradycardia and hypotension.
Respiratory: aspiration pneumonitis
GIT: Nausea, vomiting, diarrhoea
Other: Mucous membrane irritation and numbness, dermal irritation, chemical conjunctivitis and corneal scarring have been reported.
Specific Oils and associated clinical manifestations
- CLOVE: large ingestions can have hepatotoxicity similar to paracetamol poisoning, renal failure, DIC, inhalational pneumonitis, coma
- FENNEL: Nausea, vomiting, seizure activity, pulmonary oedema.
- GERANIUM: Allergic contact chelitis.
- LAVENDER: CNS depression, ataxia, photosensitiser that promotes hyperpigmentation, contact dermatitis.
- LEMON MYRTLE: Skin irritation and corrosion.
- NUTMEG: hallucinations, coma
- THUJA (essential oil of the wormwood plant of the cedar family): Multiple tonic-clonic seizures.
- WINTERGREEN (Methyl Salicylate): nausea, vomiting, tinnitus, vertigo, hyperventilation, seizures.
- WORMWOOD: Acidosis, acute renal failure, respiratory acidosis, rhabdomyolysis, visual alterations, delirium, restlessness, paranoia, tremor, and seizures.
- EUCALYPTUS: See Eucalyptus oil Poisoning
Investigations
Asymptomatic children with small ingestions do not usually require investigation.
Consider:
Chest X-ray and blood gas if signs of aspiration pneumonitis
UEC and LFTs in patient with significant illness, large ingestions or with clove oil/pennyroyal ingestions.
Paracetamol level in all intentional overdoses
Acute Management
1. Resuscitation
Standard procedures and supportive care.
Aspiration/chemical pneumonitis is managed supportively (Oxygen & bronchodilators – may require non-invasive ventilation or intubation if severe). Corticosteroids and prophylactic antibiotics are not indicated. Fever is common following aspiration with pneumonitis – antibiotics should be withheld until there is objective evidence of bacterial infection
2. Decontamination
Charcoal is contraindicated due to risk of aspiration.
3. Specific treatments
Consider NAC for significant clove oil or pennyroyal poisoning, discuss with poisons/toxicologist.
Eye irritation management: routine eye irrigation, however may require a longer duration of irrigation, as oily substances, any persistent eye symptoms should have ophthalmology review.
Ongoing care and monitoring
Asymptomatic children with significant exposure (>5 mL) and normal vital signs, including GCS, should be observed for 4 hours post exposure before discharge.
Patients with respiratory or CNS symptoms should be admitted for a longer period of observation +/- supportive care.
Enhance elimination – ineffective
Antidote – Nil
When to admit/consult local paediatric team, or who/when to phone:
Admission should be considered for all adolescent patients with an intentional overdose.
Consult Contact Victorian Poisons Information Centre 13 11 26 for advice
When to consider transfer to a tertiary centre:
Patients with significant CNS depression / seizures or respiratory compromise who should be managed in a paediatric intensive care unit.
For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.
Discharge Criteria:
Normal GCS
Period of observation as above
For deliberate ingestion a risk assessment should indicate that the patient is at low risk of further self harm in the discharge setting
Discharge information and follow-up:
Accidental ingestion: Parent information sheet from Victorian Poisons Information centre
on the prevention of poisoning
Intentional
self-harm: Referral to local mental health services e.g. Orygen Youth
Health: 1800 888 320
Recreational poisoning: Referral
to YoDAA,
Victoria's Youth Drug and Alcohol Advice service: 1800 458
685
Last updated June 2017